Hindawi BioMed Research International Volume 2017, Article ID 9348159, 8 pages https://doi.org/10.1155/2017/9348159

Research Article Mental and Reproductive Health Correlates of Academic Performance among Debre Berhan University Female Students, Ethiopia: The Case of Premenstrual Dysphoric Disorder Sisay Mulugeta Alemu,1 Tesfa Dejenie Habtewold,2 and Yohannes Gebreegziabhere Haile3 1

Mental Health and Psychosocial Support Program, International Medical Corps, Dolo Ado, Ethiopia Department of Epidemiology and Rob Giel Research Center, University of Groningen, Groningen, Netherlands 3 Department of Nursing, Debre Berhan University, Debre Berhan, Ethiopia 2

Correspondence should be addressed to Tesfa Dejenie Habtewold; [email protected] Received 22 December 2016; Accepted 24 April 2017; Published 29 May 2017 Academic Editor: Alberto Raggi Copyright © 2017 Sisay Mulugeta Alemu et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Background. Globally 3 to 8% of reproductive age women are suffering from premenstrual dysphoric disorder (PMDD). Several mental and reproductive health-related factors cause low academic achievement during university education. However, limited data exist in Ethiopia. The aim of the study was to investigate mental and reproductive health correlates of academic performance. Methods. Institution based cross-sectional study was conducted with 667 Debre Berhan University female students from April to June 2015. Academic performance was the outcome variable. Mental and reproductive health characteristics were explanatory variables. Two-way analysis of variance (ANOVA) test of association was applied to examine group difference in academic performance. Result. Among 529 students who participated, 49.3% reported mild premenstrual syndrome (PMS), 36.9% reported moderate/severe PMS, and 13.8% fulfilled PMDD diagnostic criteria. The ANOVA test of association revealed that there was no significant difference in academic performance between students with different level of PMS experience (F-statistic = 0.08, 𝑝 value = 0.93). Nevertheless, there was a significant difference in academic performance between students with different length of menses (F-statistic = 5.15, 𝑝 value = 0.006). Conclusion. There was no significant association between PMS experience and academic performance, but on the other hand, the length of menses significantly associated with academic performance.

1. Introduction Menstrual cycle is the orderly cyclic hormone production and parallel proliferation of the uterine lining to prepare for implantation of the embryo [1]. Most women report mood symptoms, behavioral changes, and physical symptoms during the menstrual cycle; however, these symptoms resolve for the rest of time between menstrual cycles. This group of symptoms are first named as premenstrual tension by Frank and later renamed to premenstrual syndrome by Greene and Dalton in 1953 [2]. There are more than 150 premenstrual symptoms registered in 10th revision of the International Statistical Classification of Diseases and Related Health Problems (ICD-10) [3]. Premenstrual syndrome (PMS) is the presence of at least one out of fourteen symptoms registered in the fifth text edition

of Diagnostic and Statistical Manual of Mental Disorders (DSM-5) [4]. Premenstrual dysphoric disorder (PMDD), a severe form of PMS, is defined as the presence of at least five out of eleven DSM-5 mood or behavioral or physical symptoms with the substantial interference of daily activities [4]. Even though up to 80% of women experience mild to severe premenstrual symptoms [5–9], they consider these symptoms as a natural event [6] and do not seek medical advice [10]. According to the DSM-5 criteria, the prevalence of PMDD was 3 to 8% [11]. In addition, 18% of reproductive age women suffered from moderate to severe premenstrual symptoms [12]. Previous studies showed that biological, psychological, and social-cultural factors cause PMDD [13]. These factors

2 include educational and marital status, genetic predisposition, age, pain during menses, amount of menstrual bleeding, history of physical and psychiatric illness, treatment seeking behavior, history of traumatic event, sleeping hour, physical exercise, and maternal history of PMS [14–26]. Women become symptomatic when the social and psychological stressors induce biochemical (hormone and neurotransmitter) changes [2]. Among others, school absenteeism and poor academic performance were the deleterious effects of PMDD [27]. Moreover, PMDD has been associated with suicide and accident rate, major depressive disorder, high job absenteeism, poor quality of life, and poor family and coworkers relationship [28, 29]. Despite a considerable effect on women daily functioning, the association between PMS experience and academic performance has given little attention [11]. Thus, the aim of this study was to investigate mental and reproductive health correlates of academic performance among female students.

BioMed Research International performance. Premenstrual symptoms experience, history of depression, history of traumatic events, sleeping hour, pain during menses, length of menses, amount of menstrual bleeding, and duration of menses were the explanatory variables. Premenstrual symptoms experience rated as no/mild PMS, moderate/severe PMS, and severe PMS or PMDD. PMDD was diagnosed if at least one out of four “core PMS” symptoms rated as “severe,” at least four additional PMS symptoms rated either “moderate” or “severe,” and at least one out of five “area of functioning” items rated “severe.” PMDD was the secondary outcome variable. Moderate/severe PMS was diagnosed if at least one out of four “core PMS” symptoms rated either “moderate” or “severe,” at least four additional PMS symptoms rated either “moderate” or “severe,” and at least one out of five “area of functioning” items rated “moderate” or “severe” [31]. If the students did not fulfill the above classifications, they were diagnosed as “no/mild PMS.” Level of pain and amount of bleeding during menses were measured and rated based on the subjective experience of students.

2. Methods and Materials 2.1. Population and Procedure. Institution based cross-sectional study was conducted at Debre Berhan University from April to June 2015. Undergraduate students who enrolled in 2014/2015 full-time study, who were capable of independent communication, and who provided informed written consent were included. All students were selected by multistage cluster sampling technique (design effect = 2). First, 5 out of 8 colleges were selected by simple random sampling technique. Second, 14 departments representing 40% of departments at Debre Berhan University were selected using simple random sampling technique. Finally, student batches (1st, 2nd, and 3rd year) were selected randomly and data was collected from the entire students. The data was collected after the class. 2.2. Sample Size Determination. The sample size was determined by single population proportion formula considering the following assumptions: 27% prevalence of PMDD in Ethiopian university students [19] and 95% confidence level. After adjustment for the design effect of 2 and 10% nonresponse rate, the final sample size was 667. 2.3. Instrument. Data was collected from 14 departments using pretested self-administered questionnaire. The questionnaire has four parts: part 1, sociodemographic characteristics; part 2, menstrual cycle characteristics; part 3, treatment seeking behavior and general health status; part 4, premenstrual symptoms and functionality. Premenstrual symptoms screening tool (PSST) was used to assess PMDD. The PSST includes a list of premenstrual psychiatric and physical symptoms, and a measure of functional impairment in accordance with DSM-5 criteria. PSST for adolescents aged ≥18 years has excellent internal consistency, Cronbach’s alpha of 0.91, and content validity of 0.91 [30]. 2.4. Variables. Academic performance was the primary outcome variable. Self-reported cumulative grade point average (CGPA) was used as a proxy measure of academic

3. Data Processing and Analysis Data was coded, entered, and cleaned using EPI Info version 3.5.1. Before analysis, continuous variables were grouped based on previous research and internationally recommended cut-off value [1]. To examine the risk factors of PMDD, first, all variables were fitted to the bivariate logistic regression model. Then, variables were included in the final multiple logistic regression model if 𝑝 value reached 0.05. Finally, independently associated risk factors were identified based on 0.05 significance level. The strength of association was determined using odds ratios with 95% confidence interval. Two-way ANOVA test of association was applied to investigate the association between academic performance and mental and reproductive health-related factors. In addition, Bonferroni post hoc test was done for multiple comparisons of groups difference in academic performance. Statistical Package for Social Science (SPSS) version 20.0 (IBM SPSS Corp.) was used for data analysis. The study was adherent to the strengthening of the reporting of observational studies in epidemiology (STROBE) statement (see Supplementary File 1: STROBE statement in the Supplementary material available online at https://doi.org/10.1155/2017/9348159).

4. Ethics Approval and Consent to Participate Debre Berhan University, Institute of Health Science and Medicine Ethical Review Board, approved the study protocol. Participation was voluntary and data was collected anonymously after obtaining written consent from each student.

5. Results 5.1. Biopsychosocial Characteristics. In total, 529 students completed the self-administered questionnaire with the response rate of 80%. The main reasons for nonresponse were a lack of interest and shortage of time. The mean age of students was 20.5 years (SD ± 1.54). More than two-thirds

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Table 1: Premenstrual symptoms and functional interference, June 2015.

No List of symptoms Anger/irritability Anxiety/tension Tearfulness/increased sensitivity to rejection Depressed mood/hopelessness Decreased interest in work activity Decreased interest in home activity Decreased interest in social activity Difficulty concentrating Fatigue/lack of energy Overeating/food craving Insomnia/difficulty of sleeping Hypersomnia (need more sleep) Feeling overwhelmed or out of control Physical symptoms (e.g., muscle pain, bloating) Area of functioning Symptoms interfered work efficiency or productivity Symptoms interfered relationship with coworkers Symptoms interfered relationship with family Symptoms interfered social life activity Symptoms interfered home responsibility

Not at all %

Mild No

%

Moderate No %

No

Severe %

180 153 239 184 137 126 158 206 110 282 264 150 228 130

34.0% 28.9% 45.2% 34.8% 25.9% 23.9% 29.9% 38.9% 20.8% 53.3% 49.9% 28.4% 43.1% 24.6%

160 162 159 140 138 167 155 150 143 158 119 139 144 105

30.2% 30.6% 30.1% 26.5% 26.1% 31.6% 29.4% 28.4% 27.0% 29.9% 22.5% 26.3% 27.2% 19.8%

139 156 102 148 174 163 148 119 165 65 101 143 105 146

26.3% 29.5% 19.3% 28.0% 32.9% 30.9% 28.0% 22.5% 31.2% 12.3% 19.1% 27.0% 19.8% 27.6%

50 58 29 57 80 72 67 54 111 24 45 97 52 148

9.5% 11.0% 5.5% 10.8% 15.1% 13.6% 12.7% 10.2% 21.0% 4.5% 8.5% 18.3% 9.8% 28.0%

163 178 180 171 174

30.8% 33.6% 34.0% 32.3% 32.9%

153 148 144 150 164

28.9% 28.0% 27.2% 28.4% 31.0%

162 144 115 150 127

30.6% 27.2% 21.7% 28.4% 24.0%

51 59 90 58 64

9.6% 11.2% 17.0% 11.0% 12.1%

(70.1%) of students were single, 50.3% were first year, and 72.4% were from Amhara ethnic group. On average students slept 8 (SD ± 2.22) hours per day. The average menstrual cycle was 29.1 days (SD ± 9.5). More than half (54.3%) of students suffered from moderate pain during menses. The mean duration of menses was 4.31 days (SD ± 1.45). Furthermore, 13.2% of students reported heavy menstrual bleeding. 5.2. Premenstrual Symptoms Experience. Almost all students (95.5%) had at least one mild premenstrual symptom, and 85.8% had moderate or severe symptoms. Fatigue or lack of energy (89.2%) was the most prevalent symptom followed by decreased interest in home activity (76.1%). Insomnia (50.1%) and overeating (46.7%) were the least prevalent symptoms (Table 1) Based on the DSM-5 criteria, 49.3% students were diagnosed with no/mild PMS, 36.9% moderate/severe PMS, and 13.8% severe PMS or PMDD (Figure 1).

6. Academic Performance The mean cumulative grade point average (CGPA) was 2.66 (SD ± 0.51). Furthermore, 97.4% of students had the CGPA of ≥2.0 and 46.5% of students had above the mean CGPA. The ANOVA test of association revealed that the mean CGPA of students who fulfilled PMDD criteria was not significantly different from students without PMDD (F-statistic = 0.08, 𝑝 value = 0.93). On the other hand, the mean CGPA of students with 35 days of length of menses was significantly different. Multiple comparisons following

50 45 40 35 30 25 20 15 10 5 0

No/mild PMS

Moderate/severe PMS

PMDD

Figure 1: Frequency distribution of premenstrual symptoms experience, June 2015.

Bonferroni post hoc test showed that the mean CGPA of students with 35 days (𝑝 value = 0.006) of length of menses (Table 2).

7. Associated Factors of PMDD The bivariate statistical modeling showed that pain during menses, amount of menstrual bleeding, maternal history of PMS, history of depression, psychiatric morbidity other than depression, and history of traumatic event were the significant risk factors of PMDD. Following multivariate modeling only pain during menses, amount of menstrual bleeding,

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BioMed Research International Table 2: Mental and reproductive health-related correlates of academic performance, June 2015.

Variables Premenstrual symptoms No/mild PMS Moderate/severe PMS PMDD History of depression Yes No History of any psychiatric morbidity other than depression Yes No History of traumatic event Yes No Sleeping status ≤5.9 hours/day 6.0–7.9 hours/day ≥8.0 hours/day Pain during menses No Minimal Moderate Severe Length of menses 35 days Amount of menstrual bleeding Minimal Moderate Heavy Duration of menses ≤3 days ≥4 days

𝑁 = 529

Mean CGPA

95% CI of mean CGPA

𝐹-statistic

𝑝 value

261 195 73

2.67 2.66 2.64

2.61–2.73 2.58–2.73 2.53–2.76

0.08

0.93

48 481

2.69 2.65

2.54–2.85 2.61–2.70

0.19

0.66

57 472

2.60 2.66

2.48–2.72 2.62–2.71

0.84

0.36

96 433

2.65 2.66

2.55–2.76 2.61–2.71

0.03

0.86

44 104 380

2.65 2.63 2.67

2.48–2.82 2.54–2.73 2.62–2.72

0.22

0.80

56 118 257 98

2.67 2.71 2.65 2.62

2.53–2.82 2.61–2.80 2.58–2.71 2.52–2.71

0.61

0.60

21 487 21

2.36 2.66 2.85

2.18–2.54 2.62–2.71 2.61–3.09

5.15

0.006

103 356 70

2.61 2.68 2.62

2.51–2.71 2.63–2.73 2.49–2.75

1.06

0.35

166 363

2.64 2.67

2.56–2.71 2.61–2.72

0.39

0.53

and treatment seeking behavior persisted as a significant associated risk factor of PMDD. Students who had severe pain during menses were 6.5 times more likely to develop PMDD compared to those who had no pain (AOR = 6.5; 95% CI = 1.6–43.7). Students who had heavy menstrual bleeding were 2.8 times more likely to develop PMDD compared to those who had minimal bleeding (AOR = 2.8; 95% CI = 1.2–7.1). Moreover, students who took the nonprescribed drug particularly pain-killers during menses were 8.5 times more likely to develop PMDD as compared to students who have used other options to manage symptoms (AOR = 8.5; 95% CI = 1.5–46.6) (Table 3).

8. Discussion There was no significant association between premenstrual symptoms (PMS) experience and academic performance, but on the other hand, the length of menses significantly

associated with academic performance. Based on the DSM5 criteria, 49.3% of students were diagnosed with no/mild PMS, 36.9% moderate/severe PMS, and 13.8% severe PMS or PMDD. Pain during menses, amount of menstrual bleeding, and treatment seeking behavior were risk factors of premenstrual dysphoric disorder (PMDD). The first objective of this study was to assess the association between academic performance and mental and reproductive health-related factors. In contrary to another study in Ethiopia [27], the current study showed that there was no significant difference in academic performance between students who fulfilled PMDD criteria and without PMDD. This does not imply that PMDD had no relevant effect on student academic performance. Therefore, this nonsignificant result might be due to two reasons. Primarily, this study had used cumulative grade point average (CGPA), which might be affected by previous semester or year grade. This justification was supported by the finding that half of the students were

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Table 3: Bivariate and multiple logistic regression model of biopsychosocial risk factors and PMDD, June 2015. Variables (reference category) Current age, ≥20 (≤19) Marital status (single) Engaged Married Ethnicity (Amhara) Oromo Tigre Others Religion (orthodox) Muslim Protestant Field of study (natural and computational science) Agriculture science Social science Business and economics Health science Bach (first year) Second year Third year Daily sleeping hour (

Mental and Reproductive Health Correlates of Academic Performance among Debre Berhan University Female Students, Ethiopia: The Case of Premenstrual Dysphoric Disorder.

Globally 3 to 8% of reproductive age women are suffering from premenstrual dysphoric disorder (PMDD). Several mental and reproductive health-related f...
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